Provider Demographics
NPI:1932568763
Name:COHEN, GARY W JR (ATC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:W
Last Name:COHEN
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:696 MOWBRAY ARCH APT 260
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1878
Mailing Address - Country:US
Mailing Address - Phone:772-475-0452
Mailing Address - Fax:
Practice Address - Street 1:5115 HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23529-8031
Practice Address - Country:US
Practice Address - Phone:772-475-0452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer